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EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis
  1. W Zhang1,
  2. M Doherty1,
  3. G Peat2,
  4. M A Bierma-Zeinstra3,
  5. N K Arden4,
  6. B Bresnihan5,
  7. G Herrero-Beaumont6,
  8. S Kirschner7,
  9. B F Leeb8,
  10. L S Lohmander9,
  11. B Mazières10,
  12. K Pavelka11,
  13. L Punzi12,
  14. A K So13,
  15. T Tuncer14,
  16. I Watt15,
  17. J W Bijlsma16
  1. 1Academic Rheumatology, University of Nottingham, Nottingham, UK
  2. 2Arthritis Research Campaign National Primary Care Research Centre, Keele University, Keele, UK
  3. 3Department of General Practice, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
  4. 4MRC Environmental Epidemiology Resource Centre, Southampton General Hospital, Southampton; Musculoskeletal Biochemical Research Unit, University of Oxford, UK
  5. 5Department of Rheumatology, St Vincent's University Hospital, Dublin, Ireland
  6. 6Servicio de Reumatologia, Fundación Jiménez Diaz, Madrid, Spain
  7. 7Universitätsklinik für Orthopädie, Dresden, Germany
  8. 82nd Department of Medicine, Centre for Rheumatology Lower Austria, Stockerau, Austria
  9. 9Department of Orthopaedics, Clinical Sciences Lund, Lund University, Lund, Sweden
  10. 10Department of Rheumatology, Larrey University Hospital, Toulouse, France
  11. 11Institute of Rheumatology, Na Slupi 4, Prague, Czech Republic
  12. 12Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Padova, Italy
  13. 13Service de RMR, Centre Hospitalier Unviersitaire Vaudois, Lausanne, Switzerland
  14. 14Department of PMR, Rheumatology Division, Akdeniz University, Antalya, Turkey
  15. 15Department of Radiology. Leiden University Medical Centre, Leiden, The Netherlands
  16. 16Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands
  1. Correspondence to Dr Weiya Zhang, Academic Rheumatology, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham NG5 1PB, UK; weiya.zhang{at}


Objective To develop evidence-based recommendations for the diagnosis of knee osteoarthritis (OA).

Methods The multidisciplinary guideline development group, representing 12 European countries, generated 10 key propositions regarding diagnosis using a Delphi consensus approach. For each recommendation, research evidence was searched systematically. Whenever possible, the sensitivity, specificity and likelihood ratio were calculated for individual diagnostic indicators and a diagnostic ladder was developed using Bayes' method. Secondary analyses were undertaken to test directly the recommendations using multiple predictive models in two populations from the UK and the Netherlands. Strength of recommendation was assessed by the EULAR visual analogue scale.

Results Recommendations covered the definition of knee OA and its risk factors, subsets, typical symptoms and signs, the use of imaging and laboratory tests and differential diagnosis. Three symptoms (persistent knee pain, limited morning stiffness and reduced function) and three signs (crepitus, restricted movement and bony enlargement) appeared to be the most useful. Assuming a 12.5% background prevalence of knee OA in adults aged ≥45 years, the estimated probability of having radiographic knee OA increased with increasing number of positive features, to 99% when all six symptoms and signs were present. The performance of the recommendations in the study populations varied according to the definition of knee OA, background risk and number of tests applied.

Conclusion 10 key recommendations for diagnosis of knee OA were developed using both research evidence and expert consensus. Although there is no agreed reference standard, thorough clinical assessment alone can provide a confident rule-in diagnosis.

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  • Funding Financial support was received from the European League Against Rheumatism.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.